Using Just Culture To Improve Hospital SOPS Results (Intro)
November 9, 2016
Presented by Westat under contract to the Agency for Healthcare Research and Quality
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Celeste Mayer, PhD
University of North Carolina Health Care System, Chapel Hill, NC
Theresa Famolaro, MPS, MS, MBA
Westat, Rockville, MD
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What is Patient Safety Culture?
The way we do things around here.
Exists at multiple levels:
Beliefs, values & norms
Shared by staff
What is Just Culture?
"An atmosphere of trust in which those who provide essential safety-related information are encouraged and even rewarded, but in which people are clear about where the line is drawn between acceptable and unacceptable behavior" (Reason, 1997)
Just Culture is an Accountable Culture
Levels of accountability:
Hospital Survey on Patient Safety Culture
- 42 items assess 12 dimensions of patient safety culture:
- Communication openness.
- Feedback & communication about error.
- Frequency of event reporting.
- Handoffs & transitions.
- Management support for patient safety.
- Nonpunitiveresponse to error.
- Organizational learning—continuous improvement.
- Overall perceptions of patient safety.
- Supv/mgrexpectations & actions promoting patient safety.
- Teamwork across units.
- Teamwork within units.
- Patient safety "grade" (Excellent to Poor).
- Number of events reported in past 12 months.
Lowest Performing Composite Results—2016 AHRQ Comparative Database
Patient Safety Culture Composites with a circle around the lowest scoring composite with an arrow indicating an opportunity for improvement.
Defining Nonpunitive Response to Error
The extent to which staff feel that their mistakes and event reports are not held against them and that mistakes are not kept in their personnel file.
Nonpunitive Response to Error Survey Items
- Staff feel like their mistakes are held against them.
- When an event is reported, it feels like the person is being written up, not the problem.
- Staff worry that mistakes they make are kept intheir personnel file.